Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s case study below:

Case Summary

73-year-old male with history of cirrhosis and colon CA, s/p resection and colostomy, presents with episodes of hematemesis and blood in colostomy bag. He was found during EGD to have bleeding esophageal varices and underwent esophageal banding.

DRG Options

Note: Full listing of secondary diagnoses and procedure code assignment not shown

Audit Considerations & Strategies

The coder originally assigned I85.01 (esophageal varices with bleeding as the principal diagnosis) with K74.60 (cirrhosis of liver) as a secondary diagnosis

Following the ICD-10-CM Index: Varix, esophagus, in (due to), cirrhosis of liver, the coder is directed to assign I85.11 (secondary esophageal varices with bleeding)

11 has an instructional note to “code first underlying disease”, which in this case is K74.60 (cirrhosis of liver)

However, the current documentation does not link the bleeding esophageal varices to the cirrhosis, so a query is necessary

Query example below:

Patient is a 73-year-old male with a history of cirrhosis who presents with one episode of hematemesis as well as noted maroon-colored blood in his colostomy bag.

Patient underwent an EGD with noted bleeding esophageal varices. To ensure the patient’s condition is accurately reflected, please select from the following options:

Bleeding esophageal varices were due to cirrhosis

Bleeding esophageal varices were unrelated to cirrhosis

Bleeding esophageal varices were due to other cause (specify)

Unable to determine

If the provider links the bleeding esophageal varices to the cirrhosis, the DRG will shift from 370 to 432

Whenever reviewing cases with bleeding esophageal varices always look to see if the underlying cause is specified by the provider

If the etiology of the varices is not documented, query for clarification